Provider Demographics
NPI:1184619249
Name:COLONIAL VISTA CARE CENTERS, LLC
Entity type:Organization
Organization Name:COLONIAL VISTA CARE CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-665-9462
Mailing Address - Street 1:681 OKANOGAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3461
Mailing Address - Country:US
Mailing Address - Phone:509-663-8564
Mailing Address - Fax:509-663-0461
Practice Address - Street 1:625 OKANOGAN AVE.
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801
Practice Address - Country:US
Practice Address - Phone:509-888-6090
Practice Address - Fax:509-665-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH1305314000000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113056Medicaid
WA4113056Medicaid